Effect of Interactive Games Based Hand Training on Hand Dexterity and Functional Outcome in Patients With Stroke

CHAPTER I INTRODUCTION Stroke is the third leading cause of disability in the world-wide due to brain tissue damage following ischemic or hemorrhagic lesions. Survivors present problems carrying out basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) and their perception of their functional outcome decreases.

Impaired fine motor control of fingers is common after stroke, reducing the ability to grasp and manipulate objects and negatively impacting daily activities and functional outcome .

Various rehabilitation approaches focusing on upper extremity motor rehabilitation, such as constraint induced movement training, task-oriented training, mental practice, and mirror therapy, have been widely applied in clinical practice, although effective to some extent, are often limited by therapist availability, treatment intensity, and patient motivation .

Hand rehabilitation after a stroke is a long process, and motivation is crucial for the patient's outcome. The treatment outcome depends not only on the physical therapist's rehabilitation process but also on the patient's motivation for the training protocols .To make rehabilitation more appealing, game-based training protocols are incorporated into the training system Smart tablets have emerged as an innovative rehabilitation tool that combines visual feedback, gamification, and repetitive task-oriented exercises to promote motor learning. These devices provide flexible and engaging environments for home-based or clinical therapy and allow real-time monitoring of progress . The interactive nature of tablet-based applications helps stimulate neuroplasticity, especially when combined with conventional physiotherapy. Furthermore, technology-enhanced rehabilitation may improve motivation, adherence, and ultimately the functional outcome for stroke survivors and developed as an approach for hemiplegia rehabilitation in the upper extremities in recent decades .

Meanwhile, smart tablet-based hand exercises delivers electrical currents to stimulate peripheral nerves, inducing muscle contractions that may enhance voluntary motor control and cortical reorganization .

Statement of the problem:

Is there a significant effect of interactive games based hand training on hand dexterity and functional outcome in patients with stroke?

Purpose of the study:

* To investigate the effectiveness of interactive games based hand training on increasing pinch grip strength in chronic stroke patients. * To investigate the effectiveness of interactive games based hand training on enhancing the functional outcome in chronic stroke patients.

Significance of the study:

Stroke is one of the leading causes of long-term disability worldwide, affecting millions of individuals annually . Among stroke survivors, approximately 80% experience upper limb impairments, with the hand being particularly affected. Decreased UL function is a common post-stroke impairment, restricting activities of daily living (ADL), with around 30% requiring assistance, and also negatively impacting functional outcome of hand for up to two-thirds of stroke patients .

Delimitations

This study will be delimited to the following aspects:

1. Forty chronic ischemic Stroke patients from both sexes 2. The age ranges from 45 to 65 3. Stroke duration between six months and two years. 4. The selected patients will be assigned randomly into to two equal groups. 5. Pinch grip strength measured by hand grip dynamometer 6. Degree of spasticity ranges from 1+ to 2 according to modified Ashworth scale. Basic Assumptions

It will be assumed that:

1. Environmental aspects will be the same for all patients during the study. 2. The psycho-physiological factors will be the same for all subjects at testing procedures and treatment. 3. All patients will exert their maximum effort during assessment and treatment. 4. The studied sample will be carefully selected to represent the whole stroke patient's population. 5. All subjects will follow instructions.

Hypothesis

* There is no significant effect of smart tablet-based training on improving hand dexterity * There is no significant effect of smart tablet-based training on increasing pinch grip strength in stroke patients. * There is no significant effect of smart tablet-based training on enhancing functional outcome in stroke patients.

CHAPTER II LITERATURE REVIEW

This chapter will review the following items:

1. Stroke 2. Hand function and assessment 3. Stroke hand rehabilitation 4. Smart tablets hand training applications

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1. Stroke:

Stroke is a sudden disruption of blood flow to the brain, resulting in the loss of neurological function. It is classified into ischemic (due to a blockage) or hemorrhagic (due to bleeding), with ischemic strokes accounting for about 85% of all cases . The resulting neurological damage varies in severity depending on the location and extent of the brain lesion. Hemiparesis-weakness on one side of the body-is among the most prevalent complications and frequently impacts the upper extremity, limiting functional performance. The need for targeted rehabilitation, especially in the early stages of stroke recovery, is therefore urgent and well-documented in current clinical guidelines .

Stroke remains one of the leading causes of adult disability globally, affecting approximately 80 million people worldwide , its affects approximately 15 million people globally each year, with nearly one-third experiencing long-term disability , with high rates of long-term physical, cognitive, and emotional impairments. Among stroke survivors, upper limb weakness is one of the most common and persistent deficits.

Stroke is the second cause of mortality and the third cause of long-term disability worldwide with 33 million stroke survivors. A majority of patients with hemispheric stroke has limited use of the affected upper limb. In the first days after stroke onset, this concerns about 80% of the patients, while deficits in upper limb capacity persist at 6 months post stroke in 30%5 to 66%6 of the hemiplegic stroke patients. One year after stroke, upper limb deficits are accompanied by higher levels of anxiety and reduced self-reported well-being. Hence, improving upper limb capacity is a major therapeutic target in stroke rehabilitation.

The impact of stroke on motor function, particularly in the upper limbs, affects an individual's ability to perform activities of daily living (ADLs), such as eating, dressing, and grooming negatively impacting independence. This impairment stems from damage to the corticospinal tract, which is crucial for voluntary motor control . Recovery is often incomplete, with only a fraction of patients regaining full function in the upper extremity without targeted rehabilitation. Consequently, enhancing motor recovery through evidence-based interventions remains a priority in stroke care Neuroplasticity-the brain's ability to reorganize itself by forming new neural connections-is the foundation of recovery after a stroke. Interventions that enhance neuroplasticity, such as task-specific training, motor learning, and stimulation techniques, have gained prominence. These interventions must be intensive, repetitive, and functionally relevant to maximize outcomes . Technologies like smart tablets and smart tablet-based hand exercises have emerged as promising tools to facilitate such recovery, particularly in chronic stroke patients who have plateaued with traditional methods. 2. Hand function and assessment:

Common upper extremity (UE) impairments after stroke include paresis, loss of fractionated movement, abnormal muscle tone, and/or changes in somatosensation. These impairments are a result of direct damage to the primary motor cortex, the primary somatosensory cortex, secondary sensorimotor cortical areas, subcortical structures, and/or the corticospinal tract. The evaluation determines the presence and severity of each impairment and how the impairments are contributing to the loss of movement and function.

The most common motor impairment seen after stroke is paresis. Paresis is a decreased ability to volitionally activate motor units and is caused by damage to the corticospinal system (the primary motor cortex, nonprime cortical motor areas, and the corticospinal tract) Clinically, paresis appears as weakness and results in slower, less accurate, and less efficient movements compared with those in neurologically intact individuals. A stroke will cause paresis on one side of the body, contralateral to the lesion brain.

The hand is structured to be able to carry out the main actions of daily life. Functional limitations of the hand, precisely because of the role it plays, constitute the greatest disability in many neurological and orthopedic pathologies Numerous measures are readily available to clinicians for the evaluation of UE function after stroke. Action Research Arm Test (ARAT), Box and Blocks Test (BB), Chedoke Arm and Hand Activity Inventory (CAHAI), Jebsene Taylor Hand Function Test (JTT), Nine-Hole Peg Test, and the Wolf Motor Function Test (WMF) : Fugl-Meyer Assessment (FMA) - upper extremity section, ABILHAND, Sequential Occupational Dexterity Assessment (SODA) ,Sollerman Hand Function Test, Grip Ability Test (GAT), Purdue Pegboard Test and Crawford Small Parts Dexterity Test.

The FMA-UL, which was widely used in studies on neurorehabilitation, was employed as one of the primary measurements in our present study to evaluate the motor impairment and recovery of upper limb. The FMA-UL (maximum: 66) applied a three-point ordinal scale from 0 to 2 to assess upper limb function, in which "0" represented "cannot perform," "1" represented "can perform partially," and "2" represented "can perform fully." A study indicated that FMA-UL ≤ 34 indicated severe to moderate motor impairment and FMA-UL ≥ 35 represented moderate-mild . In order to evaluate hand function recovery and further investigate the effect of treatments, the score of wrist and hand of the FMA (FMA-WH, maximum: 24) was also employed..

Hand function is a critical component of upper limb mobility and is essential for fine motor tasks. It includes grasping, manipulating objects, and coordinating finger movements-all of which are commonly impaired after a stroke. The loss of hand dexterity often leads to dependency and psychological distress . Restoring hand function is therefore a central goal in post-stroke rehabilitation, as it directly correlates with functional independence and community reintegration.

In post-stroke individuals, impaired hand function is often characterized by decreased pinch grip strength, poor coordination, and abnormal muscle tone such as spasticity or flaccidity. These impairments directly hinder basic and instrumental activities of daily living (ADLs and IADLs), affecting both physical and psychosocial aspects of recovery. Restoration of hand function is a predictor of successful reintegration into daily life and is thus considered a key indicator in rehabilitation progress .

Advanced technologies have enabled more accurate and quantitative assessments of hand performance. Electromyography (EMG), motion sensors, and force measurement tools are now integrated into rehabilitation settings to complement traditional scales like the ARAT or FMA-UE. These instruments allow for objective monitoring of muscle activation patterns and range of movement, which aids in customizing treatment plans and measuring subtle improvements . This data-driven approach enhances clinical decision-making and supports research on novel interventions like smart tablet and electrical stimulation therapies. 3. Stroke hand rehabilitation:

Stroke rehabilitation is a dynamic and patient-centered process aimed at restoring function through repetitive, task-specific, and goal-oriented training. Conventional hand rehabilitation includes a range of techniq